Neurotransmitter Assessment (NTA) – Physical Medicine

Please circle the appropriate number on all questions below. 0 as the least/never to 3 as the most/always.

Section A

Is your memory noticeably declining?

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3

Are you having a hard time remembering names and phone numbers?

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3

Is your ability to focus noticeably declining?

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3

Has it become harder for you to learn new things?

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3

How often do you have a hard time remembering your appointments?

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3

Is your temperament generally getting worse?

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3

Is your attention span decreasing?

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3

How often do you find yourself down or sad?

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3

How often do you become fatigued when driving compared to in the past?

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3

How often do you become fatigued when reading compared to in the past?

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3

How often do you walk into rooms and forget why?

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How often do you pick up your cell phone and forget why?

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3

Section b

How high is your stress level?

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3

How often do you feel you have something that must be done?

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3

Do you feel you never have time for yourself?

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How often do you feel you are not getting enough sleep or rest?

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Do you find it difficult to get regular exercise?

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Do you feel uncared for by the people in your life?

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Do you feel you are not accomplishing your life’s purpose?

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Is sharing your problems with someone difficult for you?

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Section C

Section C1

How often do you get irritable, shaky, or have light-headedness between meals?

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How often do you feel energized after eating?

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How often do you have difficulty eating large meals in the morning?

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How often does your energy level drop in the afternoon?

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How often do you crave sugar and sweets in the afternoon?

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How often do you wake up in the middle of the night?

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3

How often do you have difficulty concentrating before eating?

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3

How often do you depend on coffee to keep yourself going?

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How often do you feel agitated, easily upset, and nervous between meals?

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3

Section C2

How often do you get fatigued after meals?

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3

How often do you crave sugar and sweets after meals?

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3

How often do you feel you need stimulants, such as coffee, after meals?

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3

How often do you have difficulty losing weight?

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3

How much larger is your waist girth compared to your hip girth?

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3

How often do you urinate?

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3

Have your thirst and appetite increased?

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3

How often do you gain weight when under stress?

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3

How often do you have difficulty falling asleep?

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3

Section 1

Are you losing interest in hobbies?

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3

How often do you feel overwhelmed?

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3

How often do you have feelings of inner rage?

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3

How often do you have feelings of paranoia?

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3

How often do you feel sad or down for no reason?

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3

How often do you feel like you are not enjoying life?

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3

How often do you feel you lack artistic appreciation?

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3

How often do you feel depressed in overcast weather?

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3

How much are you losing your enthusiasm for your favorite activities?

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3

How much are you losing your enjoyment for your favorite foods?

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How much are you losing your enjoyment of friendships and relationships?

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3

How often do you have difficulty falling into deep, restful sleep?

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3

How often do you have feelings of dependency on others?

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3

How often do you feel more susceptible to pain?

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3

How often do you have feelings of unprovoked anger?

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3

How much are you losing interest in life?

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3

Section 2

How often do you have feelings of hopelessness?

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3

How often do you have self-destructive thoughts?

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3

How often do you have an inability to handle stress?

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3

How often do you have anger and aggression while under stress?

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3

How often do you feel you are not rested, even after long hours of sleep?

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3

How often do you prefer to isolate yourself from others?

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3

How often do you have unexplained lack of concern for family and friends?

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3

How easily are you distracted from your tasks?

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3

How often do you have an inability to finish tasks?

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3

How often do you feel the need to consume caffeine to stay alert?

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3

How often do you feel your libido has been decreased?

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3

How often do you lose your temper for minor reasons?

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3

How often do you have feelings of worthlessness?

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3

Section 3

How often do you feel anxious or panicked for no reason?

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How often do you have feelings of dread or impending doom?

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3

How often do you feel knots in your stomach?

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3

How often do you have feelings of being overwhelmed for no reason?

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3

How often do you have feelings of guilt about everyday decisions?

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3

How often does your mind feel restless?

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How difficult is it to turn your mind off when you want to relax?

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How often do you have disorganized attention?

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How often do you worry about things you were not worried about before?

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How often do you have feelings of inner tension and inner excitability?

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3

Section 4

Do you feel your visual memory (shapes & images) has decreased?

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Do you feel your verbal memory has decreased?

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Do you have memory lapses?

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Has your creativity decreased?

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Has your comprehension diminished?

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Do you have difficulty calculating numbers?

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Do you have difficulty recognizing objects & faces?

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Do you feel like your opinion about yourself has changed?

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3

Are you experiencing excessive urination?

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Are you experiencing a slower mental response?

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3

Medication History*

Please check any of the following medications you have taken in the past or are currently taking.

Noradrenergic and Specific Serotonergic Antidepressants (NaSSAs)

Remeron®

Norset®

Zispin®

Remergil®

Avanza®

Axit®

Tricyclic Antidepressants (TCAs)

Elavil®

Prothiaden®

Endep®

Adapin®

Tryptanol®

Sinequan®

Trepiline®

Tofranil®

Asendin®

Janamine®

Asendis®

Gamanil®

Defanyl®

Aventyl®

Demolox®

Pamelor®

Moxadil®

Opipramol®

Anafranil®

Vivactil®

Norpramin®

Rhotrimine®

Pertofrane®

Surmontil®

Thaden

Norpramin®

Selective Serotonin Reuptake Inhibitors (SSRIs)

Paxil®

Seromex®

Zoloft®

Seronil®

Prozac®

Sarafem®

Celexa®

Fluctin®

Lexapro®

Faverin®

Esertia®

Seroxat®

Luvox®

Aropax®

Cipramil®

Deroxat®

Emocal®

Rexetin®

Seropram®

Paroxat®

Cipralex®

Lustral®

Fontex®

Serlain®

Priligy®

Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs)

Effexor®

Pristiq®

Meridia®

Serzone®

Dalcipran®

Cymbalta®

Selective Serotonin Reuptake Enhancers (SSREs)

Stablon®

Coaxil®

Tatinol®

Monoamine Oxidase Inhibitors (MAOI s)

Marplan®

Marsilid®

Aurorix®

Iprozid®

Manerix®

Ipronid®

Moclodura®

Rivivol®

Nardil®

Propilniazida®

Adeline®

Zyvox®

Eldepryl®

Zyvoxid®

Azilect®

Dopamine Receptor Agonists

Mirapex®

Sifrol®

Requip®

Norepinephrine–Dopamine Reuptake Inhibitors (NDRIs)

Wellbutrin XL®

D2 Dopamine Receptor Blockers (antipsychotics)

Thorazine®

Acuphase®

Prolixin®

Haldol®

Trilafon®

Orap®

Compazine®

Clozaril®

Mellaril®

Zyprexa®

Stelazine®

Zydis®

Vesprin®

Seroquel XR®

Nozinan®

Geodon®

Depixol®

Solian®

Navane®

Invega®

Fluanxol®

Abilify®

Clopixol®

GABA Antagonist Competitive Binder

Romazicon®

Agonist Modulators of GABA Receptors (benzodiazepines)

Xanax®

Dalmane®

Lexotanil®

Ativan®

Lexotan®

Loramet®

Librium®

Sedoxil®

Klonopin®

Dormicum®

Valium®

Serax®

Prosom®

Restoril®

Rohypnol®

Halcion®

Magadon®

Agonist Modulators of GABA Receptors (non-benzodiazepines)

Ambien CR®

Sonata®

Lunesta®

Imovane®

Acetylcholine Receptor Agonists

Urecholine®

Isopto®

Evoxac®

Nicotone

Salagen®

Acetylcholine Receptor Antagonists (antimuscarinic agents)

AtroPen®

Atrovent®

Scopace®

Spiriva®

Acetylcholine Receptor Antagonists (ganglionic blockers)

Inversine®

Hexamethonium

Nicotine (high doses)

Arfonad®

Acetylcholine Receptor Antagonists (neuromuscular blockers)

Tracrium®

Zemuron®

Nimbex®

Anectine®

Nuromax®

Tubocurarine®

Metubine®

Norcuron®

Mivacron®

Hemicholinium-3®

Pavulon®

Acetylcholinesterase Reactivators

Protopam®

Cholinesterase Inhibitors (reversible)

Aricept®

Enlon®

Razadyne®

Prostigmin®

Exelon®

Antilirium®

Cognex®

Mestinon®

THC

Carbamate insecticides

Cholinesterase Inhibitors (irreversible)

Echothiophate

Isoflurophate

Organophosphate insecticides

Organophosphate-containing nerve agents

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